This page addresses follow-up questions and additional information pertinent to our webinar
GYN Procedure Coding: A Practical Approach .
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.
Q: If my ob-gyn performs an endometrial biopsy in addition to a colposcopy, which code should I use?
A: The appropriate code for this scenario would be the add-on code +58110 (Endometrial sampling [biopsy] performed in conjunction with colposcopy [list separately in addition to code for primary procedure]) for the biopsy.
Q: What do our providers need to document for us to use Modifier 22?
A: A clear explanation of why the procedure was more difficult or time-consuming than usual, documentation of any unexpected findings or complicating factors, or the amount of time spent on the procedure beyond what is normally expected are all acceptable.
Q: You mentioned several Chapter 7 NCCI edits, should those be applied to every patient or just Medicare patients?
A: Most commercial insurance companies use NCCI edits in their systems and some create their own, so you may need to comply with them even if you aren’t working with Medicare. Its best practice to be consistent across the board for all patients.
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Mary Bort, CPC, CPMA, CANPC, CASCC, COSC
Consultant
Mary is a consultant for The Haugen Consulting Group with over 25 years of health care industry experience. She started her career in Orthopedics which was her passion for decades. In addition to Orthopedics, she provides expertise in other specialties such as Anesthesia, Ambulatory Surgery Center, as well as most surgical specialties . She has experience working the professional fee side of coding, audit, education as well as compliance, serving both coders and physicians, as well as the surgical side. She is a Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Anesthesia Professional Coder (CANPC) Certified Ambulatory Surgery Center Coder (CASCC) and Certified Orthopedic Surgery Coder (COSC).
During her free time, she loves to do crafts, enjoys the outdoors, and the Broncos! She has 4 daughters, and 10 grandchildren which light up her life.
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